ORALS - OBS/GYNE Flashcards
UNSTABLE NDIUP (ECTOPIC) CASES
Concern for ruptured ectopic
Urgent OBS/GYNE consult
Bloodwork
- Type and screen
- INR /PTT
Management
- Emergency O blood +/- MTP
- Rhogam if RH- (50mcg less than 12wks)
- TXA 1g
follow up questions
1. Management for stable ectopic? Indications?
methotrexate
=> BHCG < 5000
=> Hemodynamically stable without evidence of rupture
=> Mass less then 3.5 cm
=> No FHR
=> Can easily follow up
=> No liver disease
=> No leukopenia
=> No thrombocytopenia
=> No renal dysfunction
- Ectopic risk factors
=> Advanced age
=> Smoking
=> History of spontaneous MC
=> IUD
=> History of infertility
=> PID
UNSTABLE AUB
Concern – hemorrhagic shock
Consult gyne
Bloodwork – BHCG
- Type and screen
- INR
MGMT
2U emergency O neg blood +/- MTP
Premarin (estrogen) 25mg IV + antiemetics
TXA 1g IV
Toradol 30mg IV
Consider – uterine packing (surgical packing / foley catheter – Bakri Balloon)
- IR for uterine artery embolization
Consider ddx and image as needed
- Polyps, adenomyosis, Leiomyosis, Malignancy
- Coagulopathy, Ovarian Dysfunction, Endometrial, iatrogenic
PID
clinical diagnosis
Bloodwork
- LFTs (Fitz Hugh Curtis)
Mgmt
- US (r/o TOA, endometritis, salpingitis)
- Admission?
- Antibiotics
Outpatient 1) CTX 250mg IM 2) doxy 500mg 7days +/- Flagyl
Inpatient 1) Cefoxitin 2g IV Q6H 2) doxy 100mg IV/PO Q12H +/- Flagyl
follow up questions
- What is the criteria for PID
Minimal
=> Lower abdo tender
=> Adnexal tender
=> CMT
Additional
=> Temp >38.3
=> WBC on microscopy of secretions
=> ESR/CRP elevated
=> Documented gonorrhea / chlamydia infection - Indications for admission
Unwell
Pregnant
Failure of outpatient therapy
Not tolerating PO abx
TOA
HIV+
Peds
DDX for genital ulcers
Herpes (painful)
Chancroid (painful)
Behcets
Syphilis
LGV
Granuloma inguinale
Causes of ovarian torsion
Tumor – teratoma, fibroma
Cyst – follicular, corpus luteum
PCOS
Endometrioma
TOA
Hyperstimulation syndrome
PREPARE DEPARTMENT FOR PREGNANT LADY
PPLPre-alert, OBS + NICU and call resus + 2ND ERP
Equipment – delivery tray, neonatal warmer, tocometer, NRP equipment, US
- tocometer
IVs into upper extremity
Bloodwork – CBC, extended chemistry, VBG, LFTs
- Uric acid (eclampsia)
- Type and screen
- Coags
- Kliehauer betke test
In preparation for delivery
- 2g ampicillin (GBS)
- Rhogam (300mcg), TXA
- SAMPLE HX – gestational age, prenatal care, multiples, meconium present, hx of vag bleeding, known placenta previa /vasa
Exam
- US – assess lay of fetus
- Abdo exam – time contractions + examine perineum
- PV exam: 1) dilation 2) effacement 3) presentation 4) head position 5) station
DIFFERENCES
positioning - upright, DISPLACE uterus
predicted difficult airway - most experienced providre
increased aspiration risk - avoid bagging
decr FRC - faster desat time
CPR - 2-3cm higher on sternum, lateral uterine displacement
**follow up **
1. Pregnant specific dx for arrest
pre-eclampsia
uterine rupture
AFE - amniotic fluid embolism
abruption
PE
peripartum cardiomyopathy
H+Ts
PPH
Call for help – pre-alert OBS+NICU
Management
-1U emergency blood +/- mtp
- etioligy – trauma, tone, tissue, thrombin
- TRAUMA: repair perineum
- TONE – assess uterine tone / remove retained products
=> uterine massage (1 hand in vagina + 1 hand on fundus)
=> medications to help with uterine contraction TOCE-M
- TXA 1g (plasminogen => plasmin – blocks)
- Oxytocin 10U IM => 10U/hr (calcium receptors)
- Carboprost 0.25mg IM (PGE2 = C/I in asthma)
- Ergot (methylergonovine) 0.25mg IM (C/I HTN)
- Misoprostol 1mg PR (PGE1
=> pack uterus / balloon tamponade (Bakri balloon)
THROMBIN
=> coag + DIC panel
PRE-ECLAMPSIA /ECLAMPSIA
Call for help – OBS
Bloodwork (CBC, ext chem, VBG) => monitor Mg
- Uric acid
- LDH
- Haptoglobin
- Fibrinogen
- Urine – protein
- Monitor for HELLP (thrombotic microangiopathy)
mgmt:
- MgSO4 4g / 15min => 2g/hr (seizures)
- Labetolol 20mg IV Q10min / hydralazine 10mg IV Q20min (HTN)
- SBP goal 160/105 (MAP >120) to maintain placental perfusion
- Consider CT brain if lateralizing signs / seizures
- Consider betamethasone , for premature lungs - 24-34week = 12mg Q124h IM x2
Consult – OBS for delivery
follow up questions
- What is the diagnostic criteria for pre-eclampsia
=> 20wks PLUS
=> 140/90 (x2) or >160/110 (x1)
PLUS
=> proteinuria - dip / >0.3mg/dL
OR
=> EOD: CEELLP
Cr >1.5
Eyes - disturbances
Encephalopathy / HA
LFTs x2ULN
Lung edema
Plt less than 100 - Diagnostic criteria for eclampsia
pre-eclampsia PLUS seizures - List warning signs of eclampsia
all EOD signs (HA, NV)
Visual changes
elevated LFTs
hyperreflexia
elevated BP >160 - Clinical findings of eclampsia / pre-eclampsia
Headache
Nausea + vomiting
Visual disturbances
SBP 160 mmHg
Hyperreflexia, clonus
Elevated: AST, LDH, uric acid - Side effects of magnesium
Hyporeflexia
Weakness
Resp depression
Hypotension / bradycardia
Stop if any of the following develop:
=> Areflexia
=> Hypoventilation
=> UOP less than 25cc/hour
REVERSAL= 2g calcium gluconate
HELLP CASE
Treat HTN (see eclampsia mgmt)
Severe RUQ – US (r/o subcapsular hematoma of liver)
Treat DIC
Steroids
Consult – deliver
follow up questions
- Lab findings of HELLP
Hemolysis: @ least 2
=> peripheral smear (schistocytes + burr cells)
=> LDH x2 ULN OR haptoglobin down
=> bili up
Elevated Liver enzymes: AST/ALT x2 ULN
Plts less than 100
AFLP findings
Signs/Symptoms
=> N/V
=> Abdo pain
=> Polydipsia / polyuria
=> Malaise/anorexia
=> Encephalopathy
=> Ascites
Lab Findings
=> Elevated bili (more than HELLP)
=> Elevated LFTs, decr plt, uric acid up
=> Hypoglycemia
=> Cr up
=>DIC (decr fibrinogen)
3RD TRIMESTER PATIENT RESUS
Resus Team + OBS, NICU
Monitors + fetal monitors
Exam – most recent US, POCUS
Airway differences
- Positioning (upright, displace uterus)
- Predict difficult airway
- Incr aspiration risk
- Avoid bagging
- Decr FRC (faster desat time)
CPR difference
- 2-3 cm higher on sternum
- Lateral uterine displacement
- 5min = resuscitative hysterectomy
MGMT – rhogam 300mcg
- TXA 1g
AMNIOTIC FLUID EMBOLUS MGMT
Treatment
- Supportive
- ACLS
- Manage coagulopathy
- Deliver fetus
- Consider ECMO
FOLLOW UP QUESTIONS
1. DDX for amniotic fluid embolus
PE, sepsis, peripartum cardiomyopathy
Dissection
Air embolism
Anaphylaxis
